Inspection Reports for Lillian G Carter Health and Rehabilitation
225 HOSPITAL STREET, PLAINS, GA, 31780
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 25, 2025, found no deficiencies and the complaint investigated was unsubstantiated. Earlier inspections showed a mix of compliance and deficiencies, with notable issues in March 2024 related to care planning, psychotropic medication monitoring, infection control, and emergency preparedness, all of which were cited during routine and life safety surveys. Prior reports also noted failures in COVID-19 data reporting in 2023 and wound care documentation in late 2021, though these were addressed in subsequent follow-ups. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in 2024 that did not result in deficiencies. The facility appears to have corrected prior deficiencies over time, with the most recent surveys showing improvement and no enforcement actions or fines listed in the available reports.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Abbreviated Survey
Census: 51
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00255514.
Complaint Details
Complaint GA00255514 was unsubstantiated.
Findings
The complaint GA00255514 was unsubstantiated and no regulatory violations were cited during the survey.
Report Facts
Census: 51
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 0
Date: Sep 17, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00250510.
Complaint Details
Complaint number GA00250510 was substantiated.
Findings
The complaint was substantiated, but no deficiencies were cited during the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 7, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Lillian G Carter Health and Rehabilitation, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 52
Deficiencies: 0
Date: May 7, 2024
Visit Reason
A health revisit survey was conducted to verify correction of all deficiencies cited during the Recertification survey conducted on March 10, 2024.
Findings
All deficiencies cited in the prior Recertification survey have been corrected.
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
A Life Safety Code revisit survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags from the prior Life Safety Code survey were noted to have been corrected during this revisit survey.
Inspection Report
Routine
Census: 53
Deficiencies: 5
Date: Mar 10, 2024
Visit Reason
A standard routine survey was conducted to assess compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B for Long Term Care Facilities.
Findings
The facility was found not in substantial compliance with multiple deficiencies including failure to ensure PASARR Level II referral, incomplete comprehensive care plans for several residents, inadequate tracheostomy care supplies, failure to monitor psychotropic medication side effects, and ineffective infection control related to labeling and storage of personal care equipment.
Deficiencies (5)
Failed to ensure a PASARR Level II referral for one resident with serious mental illness.
Failed to develop and implement comprehensive, person-centered care plans for three residents related to pain, diabetes/insulin usage, and behavior monitoring on psychotropic medications.
Failed to provide required tracheostomy care supplies including same size and smaller size tracheostomy tubes and AMBU bag at bedside for one resident.
Failed to monitor behaviors and side effects of psychotropic medications for one resident.
Failed to maintain effective infection control program related to labeling and storage of personal care equipment in multiple shared bathrooms.
Report Facts
Facility census: 53
Sample size: 25
BIMS score: 5
BIMS score: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care plan deficiencies, psychotropic medication monitoring, and tracheostomy care |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding tracheostomy care supplies and infection control findings |
| Licensed Practical Nurse DD | Licensed Practical Nurse (LPN) | Interviewed regarding behavior monitoring and medication side effects for resident R37 |
| Licensed Practical Nurse AA | Licensed Practical Nurse (LPN) | Interviewed regarding tracheostomy care supplies |
| Registered Nurse weekend supervisor | Registered Nurse (RN) | Interviewed regarding resident R30's pain and behaviors |
| MDS coordinator | Licensed Practical Nurse (LPN) and Registered Nurse (RN) | Interviewed regarding care plan development and review |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding PASARR Level II referral process for resident R45 |
| Administrator | Facility Administrator | Interviewed regarding tracheostomy care supplies and expectations |
| Physician | Resident's Physician | Interviewed regarding PASARR Level II referral for resident R45 |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 3
Date: Mar 10, 2024
Visit Reason
The inspection was conducted as a State Licensure survey from March 8 through March 10, 2024, to determine compliance with the State Long Term Care Requirements.
Findings
Deficiencies were cited related to failure to monitor behaviors and side effects of psychotropic medications for one resident, failure to maintain an effective infection control program regarding labeling and storage of personal care equipment, and failure to develop and implement comprehensive, person-centered care plans for three residents regarding pain, diabetes and insulin usage, and monitoring behaviors on psychotropic medications.
Deficiencies (3)
Failure to monitor behaviors and side effects of psychotropic medications for one resident (R37).
Failure to maintain an effective infection control program related to labeling and storage of personal care equipment in six bathrooms on one of four halls.
Failure to develop and implement comprehensive, person-centered care plans for three residents (R30 for pain, R36 for diabetes and insulin usage, and R37 for monitoring behaviors on psychotropic medications).
Report Facts
Facility census: 53
Residents reviewed for unnecessary medications: 5
Sample size for care plan review: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Interviewed regarding behavior monitoring and medication side effects documentation for resident R37 |
| Director of Nursing (DON) | Interviewed regarding nursing staff monitoring and documentation practices and acknowledged deficiencies related to behavior monitoring and medication side effects for resident R37 | |
| Assistant Director of Nursing | Interviewed confirming infection control deficiencies related to labeling and storage of personal care equipment | |
| Registered Nurse (RN) weekend supervisor | Interviewed confirming resident R30's pain status and medication usage | |
| Licensed Practical Nurse (LPN) MDS coordinator | Interviewed regarding care plan development and review processes | |
| RN MDS coordinator | Interviewed confirming lack of care plan for pain and other care areas for resident R30 | |
| Minimum Data Set (MDS) Licensed Practical Nurse (LPN) | Interviewed regarding care plan review and updates for resident R36 | |
| MDS Registered Nurse (RN) | Interviewed regarding care plan sufficiency and updates for resident R36 |
Inspection Report
Life Safety
Census: 53
Capacity: 100
Deficiencies: 4
Date: Mar 9, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with emergency preparedness and life safety code requirements, including fire safety and sprinkler system standards.
Findings
The facility was found not in substantial compliance with emergency preparedness requirements and life safety code standards, including failure to ensure staff familiarity with the emergency plan, inadequate hazardous area enclosure, sprinkler head obstruction, and sprinkler heads not free of paint and corrosion.
Deficiencies (4)
Facility's emergency preparedness plan was not in substantial compliance; administration was not familiar with the plan, failing testing and training requirements.
Hazardous area (Room 14 on Wing 1) used for storage was not smoke tight and lacked a door closer.
Sprinkler head in soiled utility room on Wing 2 near nurses station was blocked by an HVAC cabinet.
One sprinkler head in the soiled utility room on Wing 1 was painted and not free of paint and corrosion.
Report Facts
Census: 53
Total Capacity: 100
Hazardous rooms: 1
Residents at risk: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan and sprinkler deficiencies |
Inspection Report
Abbreviated Survey
Census: 51
Deficiencies: 0
Date: Jan 2, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00234515 and GA00233416.
Complaint Details
The survey investigated complaints GA00234515 and GA00233416; no deficiencies were found related to these complaints.
Findings
No deficiencies were cited related to the complaints during the survey.
Report Facts
Complaint numbers investigated: 2
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 23, 2023
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 05/15/2023 and 05/21/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 15, 2023
Visit Reason
The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 05/08/2023 and 05/14/2023 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Monitoring
Census: 57
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
A state monitoring visit was conducted at Lillian G. Carter Health and Rehabilitation on 09/08/2022 to assess compliance with nursing home program requirements.
Findings
The facility was found in compliance with nursing home program requirements during the monitoring visit.
Inspection Report
Abbreviated Survey
Census: 57
Deficiencies: 0
Date: Sep 8, 2022
Visit Reason
An Abbreviated Survey in conjunction with a Monitoring Survey was conducted to investigate Complaint Intake GA00226383.
Complaint Details
Complaint Intake GA00226383 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the survey.
Report Facts
Resident census: 57
Inspection Report
Monitoring
Census: 58
Deficiencies: 0
Date: Sep 1, 2022
Visit Reason
A state monitoring visit was conducted at Lillian G Carter on 9/1/2022 to assess compliance with nursing home program requirements.
Findings
The facility was found in compliance with nursing home program requirements during the monitoring visit.
Inspection Report
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Lillian G Carter Health and Rehabilitation facility, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 66
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
A Revisit Survey was conducted to verify correction of deficiencies cited in the May 19, 2022 Recertification Survey.
Findings
All deficiencies cited in the May 19, 2022 Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 21, 2022
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint number GA00225135.
Complaint Details
Complaint number GA00225135 was investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
The complaint was unsubstantiated and no regulatory violations were cited during the investigation.
Inspection Report
Renewal
Census: 76
Deficiencies: 0
Date: May 19, 2022
Visit Reason
A licensure survey was conducted at Lillian G. Carter Health and Rehabilitation from 5/17/2022 through 5/19/2022 to assess compliance with State Licensure Regulations.
Findings
The facility was found to be in substantial compliance with State Licensure Regulations and no State Health deficiencies were cited.
Inspection Report
Life Safety
Census: 76
Capacity: 100
Deficiencies: 0
Date: May 17, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.
Inspection Report
Deficiencies: 0
Date: Feb 21, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Lillian G Carter Health and Rehabilitation facility, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 21, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey of 12/16/2021.
Complaint Details
The revisit survey was conducted following a complaint survey dated 12/16/2021. All deficiencies from that complaint survey were corrected by 1/30/2022.
Findings
The revisit survey found that all deficiencies cited as a result of the complaint survey had been corrected as of 1/30/2022.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00214039, GA00214235, and GA00214644.
Complaint Details
Investigation of complaints GA00214039, GA00214235, and GA00214644; GA00214039 and GA00214235 unsubstantiated, GA00214644 substantiated.
Findings
Complaints GA00214039 and GA00214235 were unsubstantiated. Complaint GA00214644 was substantiated, but no State Health Deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 16, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00214039, GA00214235, and GA00214644. Complaints GA00214039 and GA00214235 were unsubstantiated, while complaint GA00214644 was substantiated.
Complaint Details
Complaints GA00214039 and GA00214235 were unsubstantiated. Complaint GA00214644 was substantiated with deficiencies related to wound care documentation and QAPI effectiveness.
Findings
The facility failed to document weekly wound assessments and treatment administration for two of three residents reviewed for pressure ulcers. Additionally, the Quality Assurance and Performance Improvement Committee failed to effectively develop, implement, and monitor a corrective action plan related to documentation omissions for wound care.
Deficiencies (2)
Failure to document weekly wound assessments and treatment administration for residents with pressure ulcers.
Quality Assurance and Performance Improvement Committee failed to effectively develop, implement, and monitor corrective action plan related to documentation omissions for wound care.
Report Facts
Wound measurement: 17
Wound measurement: 13
Wound measurement: 3.5
Wound measurement: 2
Wound measurement: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse | Interviewed on 12/2/21 regarding lack of wound documentation and QAPI concerns |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 28, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00211016.
Complaint Details
Complaint GA00211016 was investigated and determined to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated.
Inspection Report
Routine
Census: 68
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 12/28/2020 through 12/29/2020 to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 5, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints #GA00200718 and #GA00201232.
Complaint Details
Complaints #GA00200718 and #GA00201232 were investigated and found to be unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
The visit was conducted as a complaint investigation for complaint GA00204615, including a desk review from 5/4/2020 through 5/14/2020 and a COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey on July 8, 2020.
Complaint Details
Investigation by desk review of complaint GA00204615 was conducted including interviews and review of facility documentation. Onsite activities were not executed due to lack of access but will resume later. No abuse, neglect, or immediate jeopardy concerns were noted.
Findings
No deficiencies were cited during the COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey. No abuse, neglect, or immediate jeopardy concerns were noted at the time of the investigation.
Report Facts
Total census: 78
Inspection Report
Routine
Census: 78
Deficiencies: 0
Date: Jul 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with federal regulations related to emergency preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, including implementation of CMS and CDC recommended practices for COVID-19.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 24, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the Recertification survey conducted on 2019-05-02.
Findings
All deficiencies cited as a result of the Recertification survey conducted on 2019-05-02 were found to be corrected during the revisit survey on 2019-06-24.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 19, 2019
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 88
Capacity: 100
Deficiencies: 1
Date: Apr 30, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to protect cooking equipment in accordance with NFPA 96 standards, specifically the NFPA 96 hood did not provide a 6-inch overhang on the side of the stove, which could place kitchen staff at risk in the event of a kitchen fire.
Deficiencies (1)
Cooking equipment was not protected in accordance with NFPA 96; the NFPA 96 hood did not provide a 6-inch overhang on the side of the stove.
Report Facts
Census: 88
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed the finding regarding the NFPA 96 hood at the time of discovery |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 25, 2018
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The follow-up survey noted that all previously cited deficiencies had been corrected.
Inspection Report
Routine
Census: 94
Deficiencies: 0
Date: Mar 8, 2018
Visit Reason
A standard survey was conducted at Lillian G. Carter Healthcare and Rehabilitation from March 5, 2018 through March 8, 2018 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found to be in substantial compliance with the Health portion of the Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B - Requirements for Long Term Care Facilities.
Inspection Report
Life Safety
Census: 94
Capacity: 100
Deficiencies: 2
Date: Mar 5, 2018
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with fire safety requirements due to lack of approved fire sprinkler coverage in the attic area above the smoking porch and absence of a remote annunciator for the emergency power generator. These deficiencies could put residents at risk in the event of fire or power failure.
Deficiencies (2)
The attic area above the facility smoking porch was not provided with fire sprinkler coverage as required by NFPA 13.
The facility generator did not have a remote annunciator outside of the generating area in a location readily observed by staff.
Report Facts
Census: 94
Total Capacity: 100
Residents at risk: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during the tour of the facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00183377 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00183377 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00181443 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00181443 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 11, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00178304 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00178304 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 93
Deficiencies: 0
Date: May 3, 2017
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 3/09/17 Standard Survey.
Findings
All deficiencies cited as a result of the 3/09/17 Standard Survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 26, 2017
Visit Reason
A follow-up inspection was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the follow-up inspection.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 27, 2017
Visit Reason
An Abbreviated Survey was conducted to investigate Complaint GA 00172886.
Complaint Details
Investigation of Complaint GA 00172886; no citations were cited indicating no substantiated deficiencies.
Findings
The facility was found to be in substantial compliance with Federal and State Long Term Care Requirements. No citations were cited.
Inspection Report
Life Safety
Census: 91
Capacity: 100
Deficiencies: 2
Date: Mar 7, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety requirements under 42 CFR Subpart 483.70(a) and NFPA Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failures in smoke barrier construction and smoke barrier doors. Specifically, smoke barriers were not properly sealed with approved fire stop materials, and smoke barrier doors did not meet the required 1 and 3/4 inch fire-resistant construction for at least 20 minutes, placing all 91 residents at risk in the event of a fire.
Deficiencies (2)
Smoke barriers were not sealed to the deck with approved fire stop material; conduit and wiring penetrations were not sealed.
Smoke barrier doors were not constructed to resist fire for at least 20 minutes; bathroom door in wing 2 smoke barrier had a louver.
Report Facts
Census: 91
Total Capacity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to smoke barrier deficiencies |
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